Tuesday, October 12, 2010

The Physical Exam

In a couple of weeks, we will be sent out to primary care sites all over the city to learn from a physician one afternoon every other week for the next year and a half. In preparation for our OPEX (OutPatient EXperience) assignments, we have been learning the physical exam piece by piece. We are being tested tomorrow and Thursday on our physical exam skills. Not so much on whether we know what we are looking, listening or feeling for, or even really whether we can do these things correctly, but whether or not we can remember all the things one is supposed to do during a physical exam.

This morning’s New York Times had a really interesting article about the physical exam and about Dr. Verghese, one of its huge proponents as a critical tool for the diagnostician.

STANFORD, Calif. — For a 55-year-old man with a bad back and a bum knee from too much tennis, Dr. Abraham Verghese was amazingly limber as he showed a roomful of doctors-in-training a twisting, dancelike walk he had spied in the hospital corridor the day before.

He challenged them to diagnose it. Hemiplegia? Sensoryataxia?Chorea? Spastic diplegia?

“It would be a shame to have someone with a gait that’s diagnostic, and yet we can’t recognize it,” he said.

It was their introduction to a rollicking workshop on abnormal gaits that soon had them shuffling, staggering and thrashing about, challenging one another.Parkinson’s? Neuropathy? Stroke?

Dr. Verghese (ver-GEESE) is the senior associate chairman for the theory and practice of medicine atStanford University. He is alsothe authorof two highly acclaimed memoirs, “My Own Country” and “The Tennis Partner,” and a novel, “Cutting for Stone,” which is now a best seller.

At Stanford, he is on a mission to bring back something he considers a lost art: the physical exam. The old-fashioned touching, looking and listening — the once prized, almost magical skills of the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope.

Art and medicine may seem disparate worlds, but Dr. Verghese insists that for him they are one. Doctors and writers are both collectors of stories, and he says his two careers have the same joy and the same prerequisite: “infinite curiosity about other people.” He cannot help secretly diagnosing ailments in strangers, or wondering about the lives his patients lead outside the hospital.

“People are endlessly mysterious,” he said in an interview in his office at the medical school, where volumes of poetry share the bookshelves with medical texts, family photos and a collection of reflex hammers.

His sources of inspiration include W. Somerset Maugham and Harrison’s Principles of Internal Medicine. In addition to his medical degree, he has one from the writing workshop at theUniversity of Iowa.

He is out to save the physical exam because it seems to bewastingaway, he says, in an era of CT,ultrasound,M.R.I., countless lab tests and doctor visits that whip by like speed dates. Who has not felt slighted by a stethoscope applied through the shirt, or a millisecond peek into the throat?

Some doctors would gladly let the exam go, claiming that much of it has been rendered obsolete by technology and that there are better ways to spend their time with patients. Some admit they do the exam almost as a token gesture, only because patients expect it.

Medical schools in the United States have let the exam slide, Dr. Verghese says, noting that over time he has encountered more and more interns and residents who do not know how to test a patient’s reflexes or palpate a spleen. He likes to joke that a person could show up at the hospital with a finger missing, and doctors would insist on an M.R.I., aCT scanand an orthopedic consult to confirm it.

Dr. Verghese trained before M.R.I. or CT existed, in Ethiopia and India, where fancy equipment was scarce and good examination skills were a matter of necessity and pride. He still believes a thorough exam can yield vital information and help doctors figure out which tests to order and which to skip — surely a worthwhile goal as the United States struggles to control health care costs, he said.

A proper exam also earns trust, he said, and serves as a ritual that transforms two strangers into doctor and patient.

“Patients know in a heartbeat if they’re getting a clumsy exam,” he said.

Stanford recruited him in 2007, in large part because of his enthusiasm for teaching the exam. He seized the bully pulpit.

“Coming from here, it’s taken more seriously,” he said.

With colleagues, he developedthe Stanford 25, a list oftechniques that every doctor should know, like how to listen to the heart or look at blood vessels at the back of the eye. The 25 are not the only exams or even the most important ones, he emphasizes — just a place to start.

Medical School, Interrupted

At times, Dr. Verghese said, he feels almost embarrassed by all the interest in his work, because the exam techniques he is teaching are nothing more than the same ones he learned in Ethiopia and India decades ago.

Two days a week he hides out to write, in a secret office that was part of the deal he made when Stanford recruited him. His name is not even on the door; he left the names of the previous occupants. There is no land line.

Like Dr. Marion Stone, the main character in “Cutting for Stone,” Dr. Verghese was born in Ethiopia. His parents were teachers from Kerala, a Christian region in southern India. His mother had newspaper articles published there about life in Ethiopia. The family’s expectations were high.

“You were a doctor, engineer, lawyer or a failure,” Dr. Verghese said. He was always drawn to literature, but never imagined he could make living at it.

He left Ethiopia at 15 for two years of premedical studies in Madras, India, and then returned to Addis Ababa for medical school. By then his parents, worried about Ethiopia’s stability, had moved to the United States. But he had no desire to leave.

“I loved that land,” he recalled.

The medical training was rigorous. Students spent a year dissecting a cadaver, and then had to pass grueling essay exams.

“It was almost brutal,” he said. “But it left us changed in some fundamental way, like formatting a disk.”

Medical students in the United States today spend far less time studying anatomy — too little to learn it well, he said, shaking his head.

Civil war broke out in Ethiopia in 1974. Emperor Haile Selassie was deposed, and the military took over. During Dr. Verghese’s third year of medical school, the university was shut down. Soldiers were everywhere. A curfew was imposed, and troops patrolled at night in jeeps with mounted machine guns. Corpses lay in the streets. As a citizen of India, he was a foreigner, and it was time to get out. He joined his parents in Westfield, N.J.

America excited him. But he was a young man used to being on his own, thrust back into a small house with his parents, who urged him to finish his medical studies. He would have to start from scratch, earning a bachelor’s degree and then applying tomedical schools, even though he already had more than two years of medical training.

He took a night job as a hospital orderly. He liked earning a paycheck, and he bought a used car, hung out with nurses and orderlies, and dated an American girl.

“I could see my blue-collar life starting to unfold,” he said. “I’d marry a Jersey girl, we’d live in an apartment someplace and take vacations in the Poconos when we could afford it.”

He lost his way during that period, he says, and it made him the black sheep of the family.

A Passionate Return to Training

Then one night at work he had an epiphany. He picked up a book that a medical student had left behind, the Harrison textbook. It’s a medical school classic, the same book he had studied in Ethiopia. He realized how much he had already invested in medicine, and what he would be throwing away if he did not resume his training. He finished medical school in India, and then did his residency in the United States, specializing in internal medicine and infectious disease.

He worked in Tennessee during the early days of theAIDSepidemic, before there were any effective treatments. Before AIDS, he said: “I must have been a conceited ass, full of knowledge. AIDS humbled a whole generation.”

He came to know many of his patients and their families. He visited their homes, attended their deaths and their funerals. One patient, near death, awoke when Dr. Verghese arrived, and opened his shirt to be examined one last time.

“It was like an offering,” Dr. Verghese said, with tears in his eyes. “To preside over the bed of a dying man in his last few hours. I listen, I thump, I don’t even know what I’m listening for. But doing it says: ‘I will never leave you. I will not let you die in pain or alone.’ There’s not a test you can offer that does that.”

His long hours and intense involvement with his patients led to his first book, “My Own Country,” but also drained him and contributed to the failure of his first marriage. Still, it was not a mistake to get so close, he insists.

“I’ve never bought this idea of taking a therapeutic distance,” he said. “If I see a student or house staff cry, I take great faith in that. That’s a great person, they’re going to be a great doctor.”

He met his present wife, Sylvia, in El Paso, where she had started a ministry to help people with AIDS. Their son, Tristan, is 12. Dr. Verghese also has two grown sons, Jacob and Steven, from his first marriage.

The Next Generation

Making hospital rounds with students, Dr. Verghese is in his element. He is impeccably dressed under the white coat, in a crisp dress shirt, pale silk tie and sharply pressed pants. His hair has made its retreat, and what remains is trimmed too close to hide thehearing aidsthat he has reluctantly begun to wear. He loves being in the wards, he says. It is the only place where his back does not ache.

On a morning in August, he peppered four students with rapid-fire questions, mini-lectures on science and the history of medicine, pointers on presenting cases, and jokes that made them roll their eyes or laugh, or both.

“What can alcohol do to the nervous system?” he asked. Damage the cerebellum, said one. Causeseizures, said another. “Come on, I want 10,” Dr. Verghese said, insistent but not bullying.

“What’s the most important part of the stethoscope?” They stared at him. “The part between the earpieces.” They moaned.

Striding down the corridor, he told them about an unusual condition that produces silver-colored stools.

“You’ll be so impressed you’ll want to take them home,” he said.

With a group of third-year medical students, he waited until they had taken their places around a patient’s bed, then asked them to turn their backs and look away.

What had they noticed on the bedside table? A lunch tray? A book? Clues to whether the patient could eat, whether he was alert? Did he look comfortable? Or did he seem to be in pain?

“What if the patient says, ‘Whatever you do, Doc, don’t bump the bed’?” Dr. Verghese asked, bumping the bed with his hip. “Considerperitonitis.”

The patient, a man in his 80s, grinned, enjoying the show, and seemed pleased to let the students practice palpating his spleen and percussing his lungs.

“Name five things that are better outside the body than in,” he asked, not mentioning that the answer appears in his novel: fluids, fetuses, foreign bodies, feces and flatus.

As they headed to the next room, Dr. Verghese told the students: “We’re going to walk these corridors and I’m going to ask you if you notice anything unusual. I’m going to ask you about someone I see along the way. Peek into patients’ rooms as you go by.”

They gathered around the next patient, leaning in close as Dr. Verghese pointed out signs of facial weakness — inability to raise the eyebrows, a lip that rose more on one side than the other when Dr. Verghese asked to see the patient’s teeth, one eye that blinked more often than the other.

In the corridor, he said, “Here’s your question: What about the lady in the next bed?”

As she had watched them walk by, only one of her eyes had moved. Just a few of the students had noticed.

“You can’t show up at the bedside and then turn on your skills,” he said. “You have to keep your game sharp all the time.”

Outside another patient’s room, he had a group of interns and residents palpating their own thighs as he showed them a technique for finding the right place to stick the needle when culturing anabscess.

“Wow!” said one of the group, whose needle had recently missed its mark. “Amazing. This is great.”